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Hi,

I am a physician and need help badly.

I injured my right sesamoid bone while I kicked the door open with the sole of my foot last july 08 while I was out of the country.

The surgeon there said dont worry it will be just fine continue walking as usual.The foot got swollen and then improved in swelling.

My problem was some pain at the site of the sesamoid area but more importantly at the end of the day my whole right side of the body aches .Specially kneejoint back and neck .
I came back and saw my local podiatrists who suggested orthotics and surgical shoe for two months which I did.At the end of two months fracture persisted.Also i used to take shoe at home at night.

X ray of the foot shows slight(3mm or so) downward displacement of the sesamoid and a small chip fracture of sesamoid towards the distal margins. Almost like an avulsion fracture.


I have used orthotics of various types all along but still I have pain at the end of the day all the way in right kee right side of the back arms neck etc.
I did get a bone scan which lights up at the sesamoid area.

My local podiatrists are great guys smart but inspite of there efforts I am not getting better.I am very thankful for what they have done so far.

I cant walk for more than a mile at a stretch.I am very careful to do so.Running is out of question.
I can finish my rounds with careful attention to the length of hallways etc.

We did talk about local injections,and surgery.
But my podiarists are not convinced that either will help.
They feel that a good orthotics will help.

I have been working with walk shop in az and have tried various adjustments but non has been a winner.

I am open for ideas, thoughts, suggestions, treatments etc.
I can travel anywhere in the world to get it fixed if possible.

If not, even then I thank the almighty for some many blessings which I have and others may not have them.


I think it is good for a doctor himself to come to see a dead end sometime as a patient.

Thank you all for reading.
Thank you for your time.

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arizonamd

Sounds like we are in non-union territory now, with the possibility of avascular necrosis a real issue.

If a plain XR of the sesamoid is showing significant sclerosis, then I would be concerned about this giving ongoing problems.

My usual approach at this point would be to try a removable cast walker for a further 2/12, then is symptoms persist, consider surgical excision of the affected sesamoid.

You will probably need a comfortable orthotic long term, and there is a risk the other sesamoid might start hurting too.

Hope this helps,

LL

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Remember, it's just a foot.

Thank you for your input.

I'd agree with LL. A removable air cast walker would be my prefered treatment choice. The air cast has the added advantage of a rocker bottom sole.

Dr. Arizona:

First of all, I would order an MRI scan to see what the condition of the sesamoid is. The MRI will let you know if the sesamoid is fractured, has avascular necrosis, has bone edema, etc. An MRI with a dedicated extremity coil may give you the best image clarity.

Depending on the diagnosis, treatment could range anywhere from complete non-weightbearing with cam-walker/cast and crutches, walking in cam-walker brace, cortisone injections and/or surgery. If foot orthoses are being used, make sure the orthoses are made inverted with a medial heel skive and relatively large (i.e. 3-6 mm thick) "Reverse Morton's extension" to unload the sesamoids from both the compression forces from ground reaction force and tensile forces from the plantar fascia and plantar intrinsics that insert upon them.

Surgical excision of the sesamoid is a good procedure if conservative therapy has failed. Generally, one sesamoid can be excised without too much problem, as long as foot orthoses are worn post-surgically. If the sesamoid is split into two halves, then one half of the sesamoid may be surgically excised with generally good results also.

Hope this helps.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Link to review article:
http://www.podiatrytoday.com/article/2442

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

All,

Following on from the review article I linked to which stated:
"Theoretically, the hallucal sesamoids protect the flexor hallucis longus during the push-off phase of gait, absorb shock, increase FHB lever action across the first MTPJ and elevate the first metatarsal to evenly distribute weightbearing forces to the lesser metatarsal heads. In two in vitro laboratory studies on hallucal sesamoid function, Aper, et. al., concluded the prime functions of the sesamoids are maintaining a constant FHL tendon leverage across the first MTPJ and allowing the FHB muscle to stabilize the hallux during stance for controlled and levered propulsion.4,5"

If we look at the anatomy: proximal to insertion into the tibial sesamoid the tendons from the medial head of flexor hallucis brevis and abductor hallucis conjoin, while tendons from the lateral head of flexor hallucis brevis, transverse and oblique heads of adductor hallucis conjoin proximal to the the fibula sesamoid. This would suggest that function of the sesamoids is more complex than described in the article above with abduction and adduction forces being modified by the tibial and fibula sesamoid respectively. Hence cases of iatrogenic hallux valgus being reported following tibial sesamoidectomy.

However, if the observations of the researchers quoted are accurate and the primary functions of the sesamoids at the 1st metatarsophalangeal are as outlined above, why do we have two of them?

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

Dr.Kirby
Thankyou very much for your insight.
MRI was done and no evidence necrosis was noted except some edema.

Do you think that complete immobilization with plaster cast will be reasonable option.

I think that it is a little too late for immobilization casting, but if you wanted to avoid surgery at all costs, then this would be a viable option. The standard of care for treating acute sesamoid fractures is six weeks non-weightbearing in a brace or cast with crutches.

How thick is the accommodation in the forefoot extension of the orthosis for your sesamoids? Do you wear the orthoses at all times? Is the sesamoid split into pieces or does it just have a small avulsion?

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Dr.
It's been 12 months. It is not going to heal.
Have it removed and get on with your life.
Tibial sesamoids are incredibly easy to remove. Fibular sesamoids are a bit more difficult but still very successful.

With all probability once it's removed you will wonder why you waited so long.

BTW: Lucky you got your MRI now. Once we get Obama-Care I doubt very much if the Feds will pay for a sesamoid MRI!!!!!!!!

Good luck

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

and i would adivse the use of air cast walker for post surgery, since it has the rocker bottom sole to help push off for gait and it's a good tool to offload your affected area

all the best!